[Histonet] Quality In AP

[Ian R Bernard]

Yes. Any more examples of near misses in histology and cytology?  I will use these case studies and source of errors as examples.

Although this may have been obvious human error with the wrong section on the slide, a systems approach to quality improvement could have prevented this incident.

Building quality controls, assurances and improvement initiatives throughout the entire test cycle (pre analytical, analytical and post analytical) is key.

We also need to be aware of latent systems errors that may or may not be in our control but must be considered as we try to improve quality and reduce errors for patient safety.

IB

-----Original Message-----
From: Cristi Rigazio [mailto:cls71877 <@t> gmail.com] 
Sent: Sunday, March 24, 2013 9:58 AM
To: Ian R Bernard
Cc: histonet <@t> lists.utsouthwestern.edu
Subject: Re: [Histonet] Quality In AP

During a tumor board conference, a pancreatic cancer case was being reviewed.  The slide was shown and a pathologist pointed out the tissue was lung, not pancreas.  The patient was scheduled for surgery the following day.  It was promptly cancelled.  This incident started in the lab when the wrong section was placed on the slide, how it got all the way to a final report and subsequent surgery scheduling, I can't answer.  Is this the kind of example you are seeking?
Kind regards,
Cristi

Sent from my iPhone

On Mar 24, 2013, at 6:05 AM, Ian R Bernard <ibernard <@t> uab.edu> wrote:

> I'm in the process of writing a comprehensive Quality Management Program for our AP department.
> 
> I have references but would like some input from colleagues.
> 
> 
> -          Sentinel event involves death or serious physical or psychological injury.
> 
> -          Near Miss fall short of that.
> 
> Bottom-line, need some real life examples of near misses in Surgical pathology, Histopathology and Cytopathology.  Send me you input
> 
> IB
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